Screening for asymptomatic cardiovascular disease in Arab patients with diabetes.

AIM: Diabetes mellitus is a major risk factor for atherosclerosis and accordingly increased morbidity and mortality. This study aimed at screening high risk diabetic patients for atherosclerosis in different arterial territories. METHODS: All high risk asymptomatic patients attending the diabetic clinic, King Fahd Hospital of the University, Saudi Arabia were invited to be screened for peripheral arterial disease (PAD), extra-cranial cerebrovascular disease (CVD) and coronary artery disease (CAD) over one year. All participants underwent measurement of ankle brachial pressure index, carotid Duplex scan and exercise electrocardiography (ECG). All patients underwent evaluation of conventional risk factors for atherosclerosis RESULTS: One hundred and sixty nine patients were invited to be screened. Of these 138 (82%) completed all the screening tests. The mean age was 53.5±7.18 years. Seventy-five (55%) had evidence of subclinical atherosclerosis. In the atherosclerotic group, 24 patients had PAD, 47 had CVD and 30 had CAD. There were significant differences between the atherosclerotic and non-atherosclerotic groups with regard to most risk factors. In age, sex adjusted, the risk of developing atherosclerosis was significantly increased with all risk factors. Dyslipidemia had the highest association (OR 9.7, 95% CI 8.1-10.2) CONCLUSION: Participation and diagnostic yield of screening for atherosclerosis had satisfactory validity and reliability. Routine screening in high-risk diabetic patients can serve as an effective tool for diagnosis of sub clinical cardiovascular disease and provide strategies to optimize risk reduction.

Fate of left kidney after left renal vein division during management of aortic occlusive disease.

AIM: Left renal vein division (LRVD) has been used as a technical aid to gain exposure to the peri-renal aorta and to control bleeding in abdominal aortic operations. A few retrospective series studied the effects of such division on the overall renal function with contradicting results. The aim of this study was to assess the effect of such division on the left kidney during the management of aortic occlusive disease. METHODS: A prospective study was undertaken on all patients that had abdominal aortic bypass surgery for juxta-renal aortic occlusive disease scheduled between October 2003 and September 2007. Renal function was assessed by measuring serum creatinine (mg/L+/-SD) and creatinine clearance (mL/min+/-SD) preoperatively and postoperatively up to 14 days in patients who had LRVD and patients who had left renal vein intact (LRVI) which served as control. Left kidney was assessed preoperatively by performing abdominal computed tomography angiography (CTA) and postoperatively with either ultrasonography (US) or CTA depending on the serum creatinine level. RESULTS: Thirty-two patients were included in this study. Six patients had LRVD. There was no statistically significant difference between the LRVD and LRVI groups as regard mean serum creatinine, preoperatively (LRVD 1.05+/-0.31 vs LRVI 1.08+/-0.21,P=0.38) and XIV day postoperatively (LRVD 1.15+/-0.31 vs LRVI 1.09+/-0.24, P=0.34), and mean creatinine clearance, preoperatively (LRVD 94+/-17.4 vs LRVI 97.9+/-11.1, P=0.31) and XIV day postoperatively (LRVD 88.8+/-13.1 vs LRVI 94.3+/-6.7 p=0.11). CTA and US showed postoperative early diffuse swelling and congestion of the left kidney in 4 cases that had LRVD, which reverted to normal at XIV day postoperatively. CONCLUSIONS: Selective LRVD during aortic occlusive surgery does not compromise the left kidney.

Primary xanthoma of the acromion: a case report and review of the literature.

Primary "xanthoma" of the bone is a rare lesion of unsettled histogenesis that may pose a diagnostic challenge owing to its wide range of differential diagnosis. Herein, we present a case of primary xanthoma of the right acromion in a middle aged woman who had no aberrant lipid metabolism or evidence of other pre-existing bone lesions. To our knowledge, this is the second reported case of a primary xanthoma involving the acromion in an adult.

Osteosarcoma of the talus: a case report and review of the literature.

Osteosarcoma of the talus is extremely rare and only few cases have been reported in the literature. We present a case of a 33 years old male who presented with painful swelling of his left ankle joint. He underwent several radiological diagnostic modalities which showed osteolytic lesion in the posterior aspect of the left talus associated with new bone formation projecting from the posterior-medial aspect of that bone. His chest X-Ray showed multiple rounded lung metastases some of them showed calcifications. Open biopsy was performed. The histopathology confirmed the diagnosis of osteoblastic osteosarcoma of the talus.

Gastrosplenic fistula following chemotherapy for lymphoma.

Gastrosplenic fistula resulting from erosion of a primary splenic lymphoma is a very rare cause of massive upper gastrointestinal hemorrhage as compared to benign peptic ulcer disease, gastric Crohn's disease, gastric adenocarcinoma, and primary gastric and splenic lymphomas. This hemorrhage can be successfully managed by splenic artery embolization, followed by splenectomy and gastric resection. A 50-year-old patient developed a gastrosplenic fistula during a course of chemotherapy for differentiated histiocytic lymphoma. The fistula was demonstrated by CT scan with oral contrast. The fistula was followed endoscopically and noted to have closed spontaneously with confirmed closure at laparotomy. The clinical management of this complication is discussed, and the literature pertaining to this rare condition is reviewed.

Impact of pre-operative venography on the planning and outcome of vascular access for hemodialysis patients.

OBJECTIVE: Pre-operative venous mapping has increased dramatically in most dialysis units since the Dialysis Outcome Quality Initiative (DOQI) guidelines recommended a native arteriovenous venous fistula (AVF) rather than a graft for hemodialysis (HD) access procedures. However, there are conflicting consequences as a result of this policy. Some studies have showed that routine mapping has resulted in a marked increase in maturation rate while others have observed the reverse. This study aimed to evaluate the impact of pre-operative venography on the planning and outcome of AVF for our HD patients. PATIENTS AND METHODS: A prospective study was performed on all patients with end-stage renal disease (ESRD) who had HD access procedures and pre-operative venography between October 2003 and November 2005. Upper limb venography was done for all patients except those that required primary access and had visible veins. All patients had HD immediately after the venography. Access procedure selection was based on the result of the venography. The complications of venography, the surgical procedure and the outcome were recorded. RESULTS: One hundred and twenty-nine patients with ESRD who had pre-operative venography were included in this study. They were mostly middle age (mean age +/- SD = 41 +/- 15.5 yrs) with a high rate of diabetes mellitus (53%). No single complication was reported. A graft was placed in six patients (5%) only. Unsuccessful surgical exploration was 0%. Early failure was in 10 patients (8%). CONCLUSION: Pre-operative venography resulted in an increase in the number of AVFs. It can improve the results of HD access procedures by selecting the most suitable veins.

Can multi-detector computed tomographic angiography replace conventional angiography prior to lower extremity arterial reconstruction?

UNLABELLED: Computed tomographic (CT) angiography has become a valuable diagnostic technique prior to lower extremity arterial reconstruction. The purpose of this study is to evaluate its accuracy, compared to conventional angiography for planning lower limb revascularization procedures. PATIENTS AND METHODS: A prospective study was performed on all patients who underwent lower extremity arterial reconstruction procedures and had both CT angiography and conventional angiography between October 2003 and November 2005. We compared both modalities of angiography to intra-operative findings and whether a change in operative procedure would have resulted. The time for performance of both techniques and their complications were also reported. RESULTS: Sixty nine patients were included in this study. Discrepancies between intra-operative findings and CT angiography were noted in four (6%) cases while there was none with conventional angiography (p = 0.127). Disagreements between intra-operative findings and CT angiography have lead to a different procedure in three (4.5%) cases and all were infra-inguinal. The time for performance of CT angiography was significantly shorter than that for conventional angiography (2.5 +/- 0.3 minutes vs 37.5 +/- 5.2, p = 0.006). CONCLUSION: For arterial reconstructive procedures CT angiography provides a less invasive and accurate imaging with short examination time. It can be used as a primary imaging modality in evaluation of lower limb ischemia.

Pre-operative evaluation of hemodialysis access fistula. A multidisciplinary approach.

Recent guidelines published by the National Kidney Foundation Dialysis Outcome Quality Initiative (DOQI) on vascular access has suggested that for patients requiring chronic hemodialysis, the preferred site for access is a native arteriovenous fistula (AVF). The recommendation of DOQI may cause an aggressive approach for creation of fistula rather than a graft. Although fistulae have longer patency as compared to grafts, a substantial number of fistulae do not function adequately either due to failing maturation or to thrombosis directly after the operation. We analyse the perioperative factors that are associated with early failure of hemodialysis access fistulae,in order to improve their functional patency. We also highlight the importance of multi-disciplinary approach including nephrologists, vascular surgeons and radiologists in ensuring optimal vascular access for hemodialysis patients.

Correlation of laryngeal and pharyngeal carcinomas and 24-hour pH monitoring of the esophagus and pharynx.

The cause of laryngeal and pharyngeal carcinomas is likely multifactorial. Smoking is an important factor, but mucosal damage from gastroesophageal reflux may also contribute. The purpose of this study was to determine whether gastroesophageal reflux is more common in patients with laryngeal or pharyngeal carcinomas than in those without these malignancies. Over an 8-year period, we correlated the results of clinical and radiographic examinations of the pharynx and esophagus to pH monitoring results in 798 patients with a variety of upper aerodigestive tract symptoms and who underwent both pH monitoring and barium esophagography. In this group, 63 patients (52 men, 11 women) had laryngeal or pharyngeal carcinomas, and 735 patients (319 men, 416 women) had neither malignancy. Abnormal pH findings were defined as a total percentage of esophageal acid exposure time of 6% or more as determined with the esophageal probe, or any reflux event detected with the pharyngeal probe. Thirty-four of 63 patients with carcinomas (54%) had abnormal pH-monitoring results: Esophageal acid exposure was abnormal in 10 patients, pharyngeal acid exposure was abnormal in 7 patients, and acid exposure was abnormal in both areas in 17 patients. Of the 735 patients without malignancies, 365 (50%) had abnormal pH-monitoring results (p > 0.05). In this population of patients, abnormal results of pH monitoring were common, occurring in 399 (50%) of 798 patients, but no significant difference was found between results in those with and without laryngeal or pharyngeal carcinomas. Therefore, our study found that gastroesophageal reflux as shown by pH monitoring was not more common in patients with these malignancies.